Johnson, Phillip r 30Z
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Phillip Vernon Johnson Male
Date of Death Age If Veteran of U.S. Armed Forces,
06/05/2012 - 47 year; War or Dates
1- Place of Death Hospital, Institution or
6 City, Tow ll Street Address
tE! ACC XX Glens Falls Glens Falls Hospital
0 Manner of Death❑Natural Cause ❑Accident El Homicide El Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
ILI Medical Certifier Name Title
Paul Bachman Coroner
Address
Warrensburg Health Center, Warensburg, NY
Death Certificate Filed District Number Register Number
City, Towrx506 ilIR2lIXX Glens Falls 5601 269 '
❑Burial Date Cemetery or Crematory
❑Eptombment 06/08/2012 Pine View Crematorium
Address
t.Eti OCremation Queensbury, NY 12804
Date Place Removed
Z Removal and/or Held
9. ❑and/or Address
t;,;
Hold
0 Date Point of
Transportation Shipment
el by Common Destination
Carrier
El Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Maynard D. Baker Funeral Home 01130
Address •
11 Lafayette Street Queensbury, N Y 12804
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
i
Lu •
1_: Permission is hereby granted to dispose of the human remains described above as indicated.
,
Date Issued 06/06/9012 Registrar of Vital Statistics LJQA.)..Ary-..Q W....,
(signafCli e)
District Number 5601 Place Glens Falls 2 N Li
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k /"'� �
I Date of Disposition WO1, Place of Disposition iµ�ua+ Lc"*U�Ortuv�.
(address)
tli
IX (section) (lotnumber)c (grave number)
Name of Sexton or Person in Charge f Premises �►rr °��/' -�C�N�
41)1.5-._
1 (please print)
gSi natureTitle env.rn oot)
(over)
DOH-1555 (02/2004) .